SEC FORM 5 SEC Form 5
FORM 5 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
 
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
Form 3 Holdings Reported.
Form 4 Transactions Reported.
1. Name and Address of Reporting Person*
Gardner Jason M.

(Last) (First) (Middle)
180 GRAND AVENUE
6TH FLOOR

(Street)
OAKLAND CA 94612

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Marqeta, Inc. [ MQ ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director X 10% Owner
X Officer (give title below) Other (specify below)
Chief Executive Officer
3. Statement for Issuer's Fiscal Year Ended (Month/Day/Year)
12/31/2021
4. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3) 2. Transaction Date (Month/Day/Year) 2A. Deemed Execution Date, if any (Month/Day/Year) 3. Transaction Code (Instr. 8) 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) 5. Amount of Securities Beneficially Owned at end of Issuer's Fiscal Year (Instr. 3 and 4) 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 7. Nature of Indirect Beneficial Ownership (Instr. 4)
Amount (A) or (D) Price
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 3) 2. Conversion or Exercise Price of Derivative Security 3. Transaction Date (Month/Day/Year) 3A. Deemed Execution Date, if any (Month/Day/Year) 4. Transaction Code (Instr. 8) 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) 6. Date Exercisable and Expiration Date (Month/Day/Year) 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) 8. Price of Derivative Security (Instr. 5) 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) 11. Nature of Indirect Beneficial Ownership (Instr. 4)
(A) (D) Date Exercisable Expiration Date Title Amount or Number of Shares
Class B Common Stock (1) 12/06/2021 G 156,463(2) (1) (1) Class A Common Stock 156,463 $0 468,537 I See Footnote(3)
Class B Common Stock (1) 12/06/2021 G 156,463(4) (1) (1) Class A Common Stock 156,463 $0 468,537 I See Footnote(5)
Class B Common Stock (1) (1) (1) Class A Common Stock 40,235,479 40,235,479(2)(4) I See Footnote(6)
Class B Common Stock (1) (1) (1) Class A Common Stock 8,000,000 8,000,000 I See Footnote(7)
Explanation of Responses:
1. Each share of Class B Common Stock is convertible into one share of Class A Common Stock at the option of the holder and upon the occurrence of other events set forth in the Issuer's Certificate of Incorporation.
2. On December 2, 2021, the Jason Gardner 2020 GRAT, dated November 23, 2020, of which the Reporting Person is trustee, transferred 156,463 shares of Class B common Stock to The Gardner 2008 Living Trust dated March 22, 2008, of which the Reporting Person and his spouse are trustees.
3. The shares are held of record by the Reporting Person, as trustee of the Jason Gardner 2020 GRAT, dated November 23, 2020.
4. On December 2, 2021, the Jocelyne Gardner 2020 GRAT, dated November 23, 2020, of which the Reporting Person's spouse is trustee, transferred 156,463 shares of Class B common Stock to The Gardner 2008 Living Trust dated March 22, 2008, of which the Reporting Person and his spouse are trustees.
5. The shares are held of record by the spouse of the Reporting Person, as trustee of the Jocelyne Gardner 2020 GRAT, dated November 23, 2020.
6. The shares are held of record by the Reporting Person and his spouse as trustees of The Gardner 2008 Living Trust dated March 22, 2008.
7. The shares are held of record by trusts for the benefit of the Reporting Person's children and of which the trustee is an independent institution. The Reporting Person disclaims beneficial ownership of the shares held in the trusts for the benefit of the Reporting Person's children.
Remarks:
/s/ Christine Paster, Attorney-in-Fact 02/10/2022
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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